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Why Everyone is Not a Candidate?

By University of Florida Health Physicians Michael S. Okun, M.D., Hubert H. Fernandez, M.D., and Kelly D. Foote, M.D.

Though almost every patient who visits our practice, particularly those with Parkinson’s Disease are excited about Deep Brain Stimulation, and want to know how and when they can share in this “new hope”, most are not candidates.  In a study examining 174 PD patients referred for surgery at the University of Florida, less than 10% were acceptable candidates(7).  It turns out that based on our experience and the experience of many other groups, we have learned that the perceived benefit of DBS mirrors that which patients see and read about.

This perceived patient benefit often equates to cure.  Patients are bombarded with stories and video-clips of dramatic successes, but often are not briefed on the reality of reasonable perceived benefits.  It is for this reason that we have introduced a mneumonic device (UF DBS Rules, see below) which we teach patients prior to and at subsequent programming sessions after surgery.  The “DBS Rules” (below) help our PD patients to understand the importance of perceived benefits from surgery.  This program allows us to ensure the success not only of the implanting team, but of each individual patient.  We similarly educate our patients with other movement disorders as to perceived benefits of surgery.

University of Florida DBS Rules

“What to Anticipate From PD Surgery” – DBS IN PD

Does not cure.
Bilateral procedures may be needed for walking and balance problems.
Smooths out on/off fluctuations.

Improves tremor, stiffness (rigidity), bradykinesia (slowness), and dyskinesia in most cases, but does not necessarily make them go totally away.
Never improves symptoms that don’t respond to your best “on.”  For example, if gait or balance do not improvewith best medication response, it will not improve with surgery.

Programming visits many times during the first 6 months, then visits every 6 months thereafter.
Decreases medications only some of the time.

Patients with other parkinsonian syndromes besides idiopathic PD, either do not benefit, or may worsen from surgical therapy.  Though these patients may represent groups most devastated by their movement disorders they should not be offered DBS surgery at this time.

Cognitive problems associated with PD can be a contraindication to surgery, but in other disorders such as tremor, dystonia, OCD, and tic these have been less well investigated and it is unclear their effects on surgical candidacy.  Additionally, those patients who have significant thinking and memory problems may have a difficult time tolerating awake surgery, a difficult post-operative course, delayed recovery, confusion, and may ultimately worsen their overall cognitive status (author observations).

The Hippocratic aphorism of “do no harm,” applies to Deep Brain Stimulation, especially in light of the high ratio of the number of patients desiring surgery versus the low number of appropriate surgical candidates.

If you have questions or would like a consultation to see if you are a candidate please call Chris Baughman at 352-294-5431 or email at Christopher.baughman@neurology.ufl.edu